Becker's ASC Review

23 ORTHOPEDICS 'It's only a matter of time' for endoscopic spine growth By Carly Behm E ndoscopic spine surgery has a significant learning curve to overcome, but it's not out of reach for spine surgeons at any stage of their careers, Dean Perfetti, MD, told Becker's. Dr. Perfetti, of Carmel, N.Y.-based Somers Orthopaedic Surgery and Sports Medicine Group performed the first endoscopic microdiscectomy at Northern Westchester Hospital in Mount Kisco, N.Y. in August. He discussed how he tackled the endoscopic spine learning curve, how the practice is supporting his endeavors and the other spine surgery trends he's following closest. Note: is conversation was lightly edited for clarity. Question: What is your history with endoscopic spine surgery? Dr. Dean Perfetti: I trained at Texas Back Institute in Plano and was exposed to endoscopy because one of my fellowship mentors started learning it on his own and made it the centerpiece of his practice. He's very proficient in it. ere are two learning curves: one for visual orientation and one for technical skills. By the end of my fellowship, I was comfortable with the visual aspect, but the hands-on techniques are something you learn at your own pace. When I joined Somers, I had the opportunity to work at several hospitals, but Northern Westchester was particularly eager to grow with me regarding the endoscopic learning curve. Since then, I've performed this procedure on numerous patients who have been very pleased with the endoscopic approach compared to traditional or tubular methods. Q: Can you elaborate more on the learning curves? What advice do you have for early-career surgeons as well as more seasoned surgeons? DP: I co-authored a paper on the endoscopic learning curve with Peter Derman, MD, whom I trained with at the Texas Back Institute. We discussed the two learning curves. e first is understanding what you're seeing on the camera in terms of orientation. Even if you're an arthroscopist or have performed cranial endoscopy as a neurosurgeon, this is a unique anatomical location — it's not a true joint. e second learning curve is acquiring the technical skills for uniportal endoscopy, specifically transforaminal and interlaminar techniques. In our paper, we found that aer about 20 cases, surgeons generally start to feel comfortable. Operative times also decrease aer 20 cases, and that's when surgeons feel ready to move on from basic lumbar procedures to more advanced techniques like posterior cervical surgery. For younger surgeons versus more experienced ones, the latter can certainly learn endoscopy, potentially even faster. However, experienced surgeons oen already have techniques they're proficient with, which can make them hesitant to adopt new ones. ey may feel that learning endoscopy isn't worth the time when they're already achieving good outcomes with their current methods. at said, there's a significant difference between minimally invasive surgery via Spine surgeons weigh Medicare exit amid pay cuts By Carly Behm D eclining CMS rates have been a concern among physicians across the board, and spine surgeons are thinking about implications for the future of patient care as well as strategies to stay afloat. The 2025 proposed physician fee schedule includes a 2.8% pay cut. And over the past three years, the CMS conversion factor has declined. Some physicians have dropped Medicare patients altogether. According to a 2023 Kaiser Family Foundation report, 1.1% of non-pediatric physicians have dropped out of the Medicare program. Among spine surgeons, concerns about declining reimbursements are bumping up against increased demand for orthopedic care. "Changes in reimbursement models and insurance policies are certainly affecting the types of practices that surgeons are considering," Rachel Bratescu, MD, said. "The model of pure private practice is becoming less common, being largely driven by its known financial challenges, including inflation, rising costs (i.e. overhead and staffing), and declining reimbursements. Medicare reimbursement for spine procedures has been steadily decreasing over the last 15 to 20 years, which is relevant in the context of our growing aging population. If these trends in reimbursement continue, fewer surgeons may choose to accept these patients, all while the demand for care is projected to increase." For some spine surgeons, dropping Medicare patients entirely was an option that has worked long-term. Ara Deukmedjian, MD, backed out of Medicare more than a decade ago. Medicare patients who still wanted to see him paid out of their pockets, and his practice has remained strong financially. However dropping Medicare patients comes with its own obstacles. "The challenges would be if you're in an area of the country where there's a lot of neurosurgical competition and you have a lot of providers, then patients may not want to pay cash to the provider who is not part of that Medicare," Dr. Deukmedjian said. n

• Cover